Antitumor combinations containing a vegf-inhibiting agent and 5fu or a derivative thereof

ABSTRACT

This invention relates to antitumor combinations comprising a VEGF inhibitor combined with 5-fluorouracil or with a 5-fluoropyrimidine derivative that are therapeutically useful in the treatment of neoplastic diseases, and pharmaceutical compositions comprising such combinations.

The present invention relates to combinations of a VEGF inhibitor and achemotoxic agent of the class of 5-fluorouracil or 5-fluoropyrimidinesthat are useful in the treatment of neoplastic diseases.

VEGF inhibitors, which are inhibitors of vascular endothelial growthfactor, are, in the majority of cases, biological products chosen fromsoluble receptors, antisenses, RNA aptamers and antibodies. The5-fluoropyrimidine derivatives are chosen from 5-fluorouracil,capecitabine or gemcitabine, which exhibit notable antitumoral andantileukemia properties; they are particularly useful in the treatmentof ovarian cancer, breast cancer, lung cancer or colon cancer. Thepresent combination is directed in particular toward the treatment ofcolon cancer or stomach cancer.

The description and the preparation of the VEGF inhibitor preferablyused in the invention, which is a VEGF-Trap chimeric protein, isdescribed in patent application WO00/75319. There are severalembodiments of the chimeric protein. The embodiment corresponding toVEGF-Trap is that described in FIG. 24 (sequence). The VEGF-Trap used inthe invention is a fusion protein comprising the VEGFR1 signal sequencefused to the Ig domain D2 of the VEGFR1 receptor, itself fused to the Igdomain D3 of the VEGFR2 receptor, in turn fused to the Fc domain ofIgG1, also called VEGFR1R2-FcΔC1 or Flt1D2.Flk1D3.FcΔC1.

In general, the doses used, which depend on factors specific to theindividual to be treated, are between 20 and 800 micrograms per kilowhen the administration is carried out subcutaneously and from 2 to 20micrograms per kilo when the administration is carried out intravenouslyor, optionally, intranasally at a lower dose of the order of 0.01picogram to 1 mg per kilo.

The 5-fluorouracil is generally used intravenously at a dose of between500 mg/m² and 5000 mg/m² per week; as regards the 5-fluoropyrimidinederivatives such as capecitabine, they are generally used, for thelatter, orally at a dose of between 500 and 3000 mg/m² generallyadministered in two daily doses. Gemcitabine is generally usedintravenously at a dose of between 500 and 2000 mg/m² per week.

An article by H Hurwitz, L Fehrenbacher, W Novotny, T Cartwright, JHainsworth, W Heim, J Berlin, A Baron, S Griffing, E Holmgren, NFerrara, G Fyfe, B Rogers, R Ross, F Kabbinavar published in “The NewEngland Journal of Medicine” (N. Eng. J. Med. 350 (23) Jun. 3, 2004,2335-2352) has described a clinical trial proving a better survival ratewhen the combination of bevacizumab with irinotecan, 5FU and leucovorinis used compared with the same combination containing no bevacizumab.Nothing proves, in this clinical trial, that the improvement in survivalrate comes from the combination of 5FU with the bevacizumab; it may justas well come from the combination of irinotecan or of leucovorin withthe bevacizumab, or may come from the quadruple combination. Now, as itis known that each of the anticancer agents brings, along with itstherapeutic effect, toxic side effects, it appears to be opportune tolimit their presence as much as possible, especially when the sameeffect can be obtained in the absence of at least one of them. In thepresent case, it is known that irinotecan leads to considerablediarrhea, which has sometimes led to the treatment having to be stopped.Furthermore, this article does not prove any synergistic effect withinCorbett's meaning, i.e. an effect that cannot be obtained with each ofthe elements of the combination used alone at its maximum tolerateddose.

It has now been found, and it is this that forms the subject of thepresent invention, that the effectiveness of VEGF inhibitors can beconsiderably improved when they are administered in combination with atleast one substance therapeutically useful in anticancer treatments thathas a mechanism of action different from that of the VEGF inhibitors.

Moreover, since the activity of the products depends on the doses used,it is possible to use higher doses and to increase the activity bydecreasing the phenomena of toxicity or delaying their appearancethrough the combination with the VEGF inhibitors or with their analogsof other therapeutically active substances, of growth factors ofhematopoietic type, such as G-CSF or GM-CSF, or certain interleukins.

More particularly, the invention relates to the combinations ofVEGF-Trap with 5-fluorouracil or derivatives thereof such ascapecitabine or gemcitabine. It also relates to the combinations alsoincluding folinic acid generally combined with 5-FU.

The improved effectiveness of a combination according to the inventioncan be demonstrated by determining the therapeutic synergism.

A combination shows therapeutic synergism if it is therapeuticallysuperior to one or other of the constituents used at its optimum dose[T. H. Corbett et al., Cancer Treatment Reports, 66, 1187 (1982)].

In order to demonstrate the effectiveness of a combination, it may benecessary to compare the maximum tolerated dose of the combination withthe maximum tolerated dose of each of the individual constituents in thestudy under consideration. This effectiveness can be quantified, forexample by the log₁₀ of the killed cells, which is determined accordingto the following formula:

log₁₀killed cells=T−C(days)/3.32×T _(d)

in which T−C represents the delay in growth of the cells, which is theaverage time, in days, for the tumors of the treated group (T) and thetumors of the control group (C) to reach a predetermined value (1 g, forexample) and T_(d) represents the time, in days, required for the volumeof the tumor to double in the control animals [T. H. Corbett et al.,Cancer, 40, 2660.2680 (1977); F. M. Schabel et al., Cancer DrugDevelopment, Part B, Methods in Cancer Research, 17 3-51, New-York,Academic Press Inc. (1979)]. A product is considered to be active iflog10 killed cells is greater than or equal to 0.7. A product isconsidered to be very active if the log₁₀ killed cells is greater than2.8.

The combination, used at its own maximum tolerated dose, in which eachof the constituents will be present at a dose generally less than orequal to its maximum tolerated dose, which show therapeutic synergy whenthe log₁₀ killed cells is greater than the value of log₁₀ killed cellsof the best constituent when it is administered alone.

The effectiveness of the combinations on solid tumors can be determinedexperimentally in the following way:

30 to 60 mg of an MC 13/C mammary tumor fragment are transplantedbilaterally, subcutaneously, into the animals subjected to theexperiment, generally mice, on day 0. The animals bearing the tumors arerandomized before being subjected to the various treatments andcontrols. In the case of treatment of advanced tumors, the tumors areleft to develop until the desired size, the animals havinginsufficiently developed tumors being eliminated. The animals selectedare divided up randomly so as to undergo the treatments and thecontrols. Animals not bearing tumors can also be subjected to the sametreatments as the tumor-bearing animals in order to be able todissociate the toxic effect from the actual effect on the tumor. Thechemotherapy generally begins from 3 to 22 days after the tumortransplant, according to the type of tumor, and the animals are observedevery day. The various groups of animals are weighed three or four timesa week until the maximum weight loss is obtained, and then the groupsare weighed at least once a week until the end of the trial.

The tumors are measured two or three times a week until the tumorreaches approximately 2 g or until the animal's death if the latteroccurs before the tumor reaches 2 g. The animals are autopsied when theyare sacrificed.

The antitumor activity is determined as a function of the variousparameters recorded.

To study the combinations on leukemias, a given number of cells aretransplanted into the animals and the antitumor activity is determinedby the increase in survival time of the treated mice compared with thecontrols. A product is considered to be active if the increased survivaltime is greater than 27% and it is considered to be very active if it isgreater than 75% in the case of P388 leukemia.

By way of examples, the following tables give the results obtained withcombinations of VEGF-Trap and 5-fluorouracile used at their optimumdose.

The present invention also relates to the pharmaceutical compositionscontaining the combinations according to the invention.

The products that constitute the combination can be administeredsimultaneously, separately or spread out over time so as to obtain themaximum effectiveness of the combination; it being possible for eachadministration to have a variable duration ranging from complete rapidadministration to continuous infusion.

It results therefrom that, for the purpose of the present invention, thecombinations are not only limited to those which are obtained byphysical combination of the constituents, but also to those which allowa separate administration which may be simultaneous or spread out overtime.

The compositions according to the invention are preferably compositionsthat can be administered parenterally. However, these compositions maybe administered orally.

The compositions for parenteral administration are generally sterilepharmaceutically acceptable solutions or suspensions which mayoptionally be prepared extemporaneously at the time of use. For thepreparation of nonaqueous solutions or suspensions, natural plant oilssuch as olive oil, sesame oil or paraffin oil or injectable organicesters such as ethyl oleate can be used. The aqueous sterile solutionsmay consist of a solution of the product in water. The aqueous solutionsare suitable for intravenous administration insofar as the pH issuitably adjusted and isotonicity is effected, for example by means of asufficient amount of sodium chloride or glucose. The sterilization canbe carried out by heating or by any other means that does not impair thecomposition. The combinations may also be in the form of liposomes or inthe form of a combination with carriers such as cyclodextrins orpolyethylene glycols.

In the combinations according to the invention, the application of theseconstituents may be simultaneous, separate or spread out over time, itis particularly advantageous for the amount of VEGF-Trap derivative torepresent from 2 to 80% by weight of the combination, it being possiblefor this content to vary according to the nature of the substancecombined, to the desired effectiveness and to the nature of the cancerto be treated.

“Pharmaceutically effective amount” is meant to describe an amount ofthe combinations according to the present invention, and constituentsthereof, effective in producing the desired therapeutic effect. Theconstituents of the combinations according to the invention may beadministered in dosages which are pharmaceutically effective for eachconstituent, or in dosages which are sub-clinical, i.e., less thanpharmaceutically effective for each, or a combination thereof, providedthat the combined dosages are pharmaceutically effective.

The combinations according to the invention are particularly useful inthe treatment of colon and/or stomach cancers. In particular, they mayhave the advantage of being able to use the constituents at doses thatare much lower than those at which they are used alone.

The following example illustrates a combination according to theinvention.

EXAMPLE

Ampoules of 1 cm³ containing 25 mg of VEGF-Trap, which are diluted in aphosphate buffer, are prepared, according to the usual technique, forsubcutaneous administration.

0.2 ml per mouse is prepared, according to the usual technique, forintravenous administration, from a commercial solution of 5 cm³containing 250 mg of 5 FU to be diluted with 5% glucose in water.

These solutions are administered simultaneously, after suitabledilution, by infusion.

The treatment can be repeated several times per day or per week untilpartial or complete remission or recovery.

Dosage in mg/kg/day (total dose in mg/kg) sc VEGF- % weight Trap Deathloss at (day 4, 7, iv 5-FU due the 11, 14, 18, (day 4, 11, to the lowestT-C 21) 18) treatment point % T/C days lck 40 (240) — 0/5 2.3 4 12.7 1.425 (150) — 0/5 1.1 8 13.9 1.5 10 (60)  — 0/5 1.1 9 12.1 1.3 2.5 (15)   —0/5 0.9 32 5.2 0.6 — 145 (435)  1/5 8.7 Toxic — — — 90 (270) 0/5 4.8 012.5 1.3 — 55.8 (167.4) 0/5 1.1 12 7.8 0.8 — 34.6 (103.8) 0/5 +2.3 344.6 0.5 40 (240) 90 (270) 0/5 8.0 0 25.2 2.7 25 (150) 90 (270) 0/5 9.6 024.8 2.7 10 (60)  90 (270) 0/5 7.4 0 23.1 2.5 10 (60)  55.8 (167.4) 0/54.4 0 16.5 1.8 10 (60)  34.6 (103.8) 0/5 5.4 1 20.0 2.2 2.5 (15)   90(270) 0/5 7.0 0 20.4 2.2 2.5 (15)   55.8 (167.4) 0/5 2.0 0 18.0 1.9 2.5(15)   34.6 (103.8) 0/5 2.0 6 11.7 1.3 BCM-1428 (May 28, 2004-Jul. 30,2004): tumor doubling time = 2.8 days. Average time for 750 mg oncontrols = 22.2 d. Treatment period = 18 d for VEGF-Trap andcombination, and 15 days for 5-FU. Abbreviations used: T/C = inhibitionof tumor growth at day 24, (T-C) delay of tumor growth, lck = log cellskilled.

What is clamed is:
 1. A pharmaceutical composition comprising apharmaceutically effective amount of a VEGF inhibitor and apharmaceutically effective amount of 5-fluorouracil, and apharmaceutically acceptable excipient.
 2. A pharmaceutical compositioncomprising a pharmaceutically effective amount of a VEGF inhibitor and apharmaceutically effective amount 5-fluoropyrimidine derivative, and apharmaceutically acceptable excipient.
 3. A method of treating aneoplastic disease, in a patient in need of such treatment, comprisingadministering to such patient a pharmaceutically effective amount of acombination of a VEGF inhibitor and 5-fluorouracil,
 4. A method oftreating a neoplastic disease, in a patient in need of such treatment,comprising administering to such patient a pharmaceutically effectiveamount of a combination of a VEGF inhibitor and a 5-fluoropyrimidinederivative.
 5. A pharmaceutical composition according to claim 2 whereinthe 5-fluoropyrimidine derivative is capecitabine or gemcitabine.
 6. Amethod according to claim 4 wherein the 5-fluoropyrimidine derivative iscapecitabine or gemcitabine.
 7. A method according to either of claim 3or 4, wherein the VEGF inhibitor is VEGF-Trap.
 8. A pharmaceuticalcomposition according to either of claims 1 or 2 wherein the VEGFinhibitor is VEGF-Trap.
 9. A pharmaceutical composition according toclaim 5 wherein the VEGF inhibitor is VEGF-Trap.
 10. A method accordingto claim 6 wherein the VEGF inhibitor is VEGF-Trap.
 11. A pharmaceuticalcomposition according to either of claim 1 or 2, further comprisingfolinic acid.
 12. A method according to either of claim 3 or 4, furthercomprising administering a pharmaceutically effective amount of folinicacid.
 13. A method according to claim 3 wherein the VEGF inhibitor and5-fluorouracil are administered simultaneously.
 14. A method accordingto claim 3 wherein the VEGF inhibitor and 5-flourouracil areadministered separately.
 15. A method according to claim 4 wherein theVEGF inhibitor and the 5-fluoropyrimidine inhibitor are administeredsimultaneously.
 16. A method according to claim 4 wherein the VEGFinhibitor and the 5-fluoropyrimidine inhibitor are administeredseparately.
 17. A pharmaceutical composition according to claim 1wherein the VEGF inhibitor is VEGF-Trap, and wherein the VEGF-Trap ispresent in the amount of 2% to 80% by weight of the total weight ofVEGF-Trap and 5-fluorouracil.
 18. A pharmaceutical composition accordingto claim 2 wherein the VEGF inhibitor is VEGF-Trap, and wherein theVEGF-Trap is present in the amount of 2% to 80% by weight of the totalweight of VEGF-Trap and the 5-fluoropyrimidine derivative.
 19. A methodaccording to claim 3 wherein the VEGF inhibitor is VEGF-Trap, andwherein the VEGF-Trap is administered in an amount of 2% to 80% byweight of the total weight of VEGF-Trap and 5-fluorouracil.
 20. A methodaccording to claim 4 wherein the VEGF inhibitor is VEGF-Trap, andwherein VEGF-Trap is administered in an amount of 2% to 80% by weight ofthe total weight of VEGF-Trap and the 5-fluoropyrimidine derivative. 21.A pharmaceutical composition according to claim 1, further comprisingfolinic acid, provided that no other chemotoxic derivative is present,and which exhibits a therapeutically synergistic effect in the treatmentof neoplastic disease.
 22. A pharmaceutical composition according toclaim 2, further comprising folinic acid, provided that no otherchemotoxic derivative is present, and which exhibits a therapeuticallysynergistic effect in the treatment of neoplastic disease.
 23. A methodaccording to claim 3, further comprising administering apharmaceutically effective amount of folinic acid, provided that noother chemotoxic derivative is administered, and wherein the amounts ofthe VEGF inhibitor, 5-fluorouracil and folinic acid administered exhibita therapeutically synergistic effect in the treatment of the neoplasticdisease.
 24. A method according to claim 4, further comprisingadministering a pharmaceutically effective amount of folinic acid,provided that no other chemotoxic derivative is administered, andwherein the amounts of the VEGF inhibitor, the 5-fluoropyrimidinederivative and folinic acid administered exhibit a therapeuticallysynergistic effect in the treatment of the neoplastic disease. 25.Combinations containing a VEGF inhibitor with at least 5-fluorouracil ora 5-fluoropyrimidine derivative that is therapeutically useful in thetreatment of neoplastic diseases.
 26. Combinations containing a VEGFinhibitor with 5-fluorouracil or capecitabine or gemcitabine.
 27. Thecombinations as claimed in claim 26, containing a VEGF inhibitor withfluorouracil.
 28. The combinations as claimed in claim 27, containing aVEGF-Trap inhibitor with 5-fluorouracil.
 29. The combinations as claimedin any one of claims 25 to 28, which also contain folinic acid.
 30. Thecombinations as claimed in one of claims 25 to 28, which contain from 2to 80% by weight of VEGF-Trap.
 31. The combinations as claimed in claim25, which also contain folinic acid, and which contain from 2 to 80% ofVEGF-Trap.
 32. The combinations as claimed in claim 26, which alsocontain folinic acid, and which contain from 2 to 80% of VEGF-Trap. 33.The combinations as claimed in claim 27, which also contain folinicacid, and which contain from 2 to 80% of VEGF-Trap.
 34. The combinationsas claimed in claim 28, which also contain folinic acid, and whichcontain from 2 to 80% of VEGF-Trap.
 35. Products containing a VEGFinhibitor and at least one therapeutically useful substance as definedin one of claims 25 to 28, in the treatment of neoplastic diseases, as acombined preparation for simultaneous use, separate use or use spreadout over time in anticancer therapy.
 36. Products containing a VEGFinhibitor and at least one therapeutically useful substance as definedclaim 25, and which may contain folinic acid, in the treatment ofneoplastic diseases, as a combined preparation for simultaneous use,separate use or use spread out over time in anticancer therapy. 37.Products containing a VEGF inhibitor and at least one therapeuticallyuseful substance as defined claim 26, and which may contain folinicacid, in the treatment of neoplastic diseases, as a combined preparationfor simultaneous use, separate use or use spread out over time inanticancer therapy.
 38. Products containing a VEGF inhibitor and atleast one therapeutically useful substance as defined claim 27, andwhich may contain folinic acid, in the treatment of neoplastic diseases,as a combined preparation for simultaneous use, separate use or usespread out over time in anticancer therapy.
 39. Products containing aVEGF inhibitor and at least one therapeutically useful substance asdefined claim 28, and which may contain folinic acid, in the treatmentof neoplastic diseases, as a combined preparation for simultaneous use,separate use or use spread out over time in anticancer therapy. 40.Combinations containing a VEGF inhibitor with at least 5-flurorouracilor a 5-fluoropyrimidine derivative and folinic acid with the exclusionof any other chemotoxic derivative exhibiting a therapeuticallysynergistic effect in the treatment of neoplastic diseases.